State of New York



State of New York

Office of the State Comptroller

UNDELIVERABLE PAYROLL CHECK REPORT

Date ________________________________

Agency ________________________________________ Dept/Division Code ____________________

Fiscal Officer ___________________________________ Phone Number ________________________

Payee’s Name ___________________________________ Check No. ____________________________

Check Box

ACTIVE / INACTIVE

|Warrant Number |Schedule/Batch Number |Amount of Check |

| | | |

| | | |

| | | |

Reason for Return:

Death of Employee Pending Documentation

Current Address Unknown

Other (Explanation) ________________________________________________________

_________________________________________________________________________________________

FOR AGENCY USE ONLY FOR TREASURY USE ONLY

Approved by: Received by:

Signature: Signature:

Date: Date:

Send form to:

Department of Taxation and Finance

Division of the Treasury

P.O. Box 22119, Albany, NY 12201-2119

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